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Vol.18, No.

5 May 1996 V

Continuing Education Article

Urinary Incontinence
FOCAL POINT
in Dogs and Cats.
★ Urinary incontinence in dogs and
cats can be accompanied by
Part II. Diagnosis and
increased or decreased urethral
pressure. Management*
KEY FACTS
North Carolina State University
■ Partial structural obstruction of Jody L. Gookin, DVM
the urethra can result in urinary
Elizabeth A. Stone, DVM, MS
incontinence.
Nicholas J. Sharp, MRCVS, PhD
■ Urethral pressure measurements
are usually normal in dogs with
reflex dyssynergia.

■ Acquired incompetence of the


urethral sphincter mechanism in
R esting urethral pressure of incontinent dogs and cats can be increased
or decreased from normal values. This pressure can be altered by
changes in the intraluminal diameter of the urethra or by changes in
urethral compliance. Urethral pressure profilometry is often used to evaluate
urethral function between episodes of voluntary urination. Part I discussed the
spayed female dogs can often be
physiology of urethral pressure, the techniques for urethral pressure profilome-
treated with estrogen or
try and electromyography, and causes of variability in the results of these pro-
phenylpropanolamine.
cedures. This part discusses the diagnosis and management of some common
conditions that lead to urinary incontinence in dogs and cats, including the
■ Urinary incontinence is a frequent
role of urethral pressure profilometry.
complication of prostatic disease
Acquired incompetence of the urethral sphincter mechanism is a common
or prostate surgery.
cause of urinary incontinence in spayed female dogs. Ureteral ectopia, prostate
problems, perineal urethrostomy, and lower motoneuron disease can also lead
■ In cats, urinary incontinence and
to urinary incontinence. Urethral pressure profilometry is often used in the
lower urinary tract infection may
clinical evaluation of urinary incontinence in dogs and cats (see the box for di-
follow perineal urethrostomy.
agnostic differentials). It can also be used to evaluate the effect of urethral
surgery on urethral function and the efficacy of drugs used to manipulate ure-
thral pressure.

INCREASED URETHRAL PRESSURE


Structural Obstruction
Urethral obstruction can be structural or functional and is characterized by
increased urethral pressure.1 Complete urethral obstruction is rarely difficult to
*Part I of this two-part presentation appeared in the April 1996 (Vol.18, No. 4) issue of
Compendium.
Small Animal The Compendium May 1996

diagnose, but partial ob- that affected dogs are typi-


struction may obstruct urine Differential Diagnosis of cally males7 and often have
flow only intermittently and no other discernable neuro-
may cause paradoxical uri- Urinary Incontinence Resulting logic abnormalities. These
nary incontinence.2 Urinary from Altered Urethral Function dogs have distended blad-
incontinence results when ders that are difficult to ex-
intravesical pressure exceeds Increased Urethral Pressure press but easy to catheter-
the increase in resting ure- (urethral obstruction) ize. 1 An interrupted urine
thral pressure caused by the Structural stream, strangury, and a
partial obstruction.3 Urolith large residual urine volume
Because a urethral catheter Neoplasia are often observed.7
may be passed without dif- Stricture The urethral obstruction
ficulty in a patient with a Mucosal flap or polyp in reflex dyssynergia has
partial structural urethral Urethral plug been attributed to excess
obstruction,2 additional di- Inflammatory or infiltrative disease sympathetic stimulation of
agnostic tests to rule out a Prostatomegaly the urethral smooth mus-
structural lesion are warrant- Periurethral mass cle and external urethral
ed before the clinical signs sphincter 1,2,8–11 or reflex
can be attributed to a func- Functional hyperactivity of the exter-
tional obstruction. 2 Diag- Reflex dyssynergia nal urethral sphincter.1,12,13
nostic tests for partial struc- Sympathetic The dyssynergia in hu-
tural obstruction include Somatic mans results from a par-
urethral palpation per rec- tial spinal cord lesion lo-
tum, survey abdominal ra- Decreased Urethral Pressure cated cranial to the sacral
diographs, and radiographic (urethral incompetence) spinal cord. 3,7 Perhaps a
contrast studies of the ure- Acquired urethral sphincter mechanism spinal cord lesion in this
thra. If these tests fail to re- incompetence location can interrupt the
veal a partial structural ure- Congenital urethral sphincter mechanism inhibitory reflex pathways
thral obstruction, urethral incompetence from the sacral spinal cord to
pressure profilometry may Prostatic disease or prostatic surgery the hypogastric nerve in the
be of value. Profilometry has After perineal urethrostomy lumbar cord, thus leading to
been used to identify partial Chronic urethral inflammatory/infiltrative elevated urethral smooth
structural obstruction by disease muscle tone during the de-
documenting a focal area of Lower motoneuron disease trusor reflex (sympathetic
increased urethral pressure. Pudendal denervation reflex dyssynergia). 1,2,8–11,14
The site of obstruction Cauda equina syndrome Spinal cord injury cranial to
along the urethra can be es- Dysautonomia the origin of the pudendal
timated from the position of nerve can interrupt descend-
the pressure rise in the pro- ing inhibitory pathways to
file.1,4 the pudendal nerve and result in increased reflex activity
of the external urethral sphincter during the detrusor
Functional Obstruction reflex (somatic reflex dyssynergia).1,12
A presumptive diagnosis of functional urethral ob- Because urethral pressure profilometry measures only
struction is based on the history, physical examination resting urethral pressure, the profiles of dogs with reflex
findings, observation of urination, absence of structural dyssynergia are usually normal. A normal urethral pres-
urethral obstruction, and increased residual urine vol- sure profile in association with other clinical signs of
ume. The normal residual volume is 0.2 to 0.5 ml/kg.5 reflex dyssynergia can help establish the diagnosis.
Several forms of functional urethral obstruction have Definitive diagnosis of reflex dyssynergia in humans is
been recognized. based on simultaneous measurement of bladder pres-
sure, urine flow rate, and urethral electromyographic
Reflex Dyssynergia activity during all phases of micturition.7,15 Although
In reflex dyssynergia, the urethra does not relax dur- these techniques are commonly used to diagnose func-
ing detrusor contraction.6 Anecdotal reports suggest tional urethral obstruction in humans,16 they are gener-

PARTIAL STRUCTURAL OBSTRUCTION ■ CATHETERIZATION ■ SPINAL LESION


The Compendium May 1996 Small Animal

ally unavailable in veterinary teaching institutions; only therapy designed to relax smooth and skeletal muscle of
one report has described their clinical use in dogs.15 the urethra is often chosen. Documentation by urethral
To differentiate sympathetic from somatic reflex pressure profilometry of a drug’s ability to decrease ure-
dyssynergia in humans, fluoroscopy is used during uro- thral pressure can provide a useful guide for drug selec-
dynamic testing to determine the site of obstruction to tion. However, resolution of the functional obstruction,
urine flow.16 As an alternative, simultaneous measure- rather than a measured decrease in urethral pressure, is
ments of pressure in the bladder and urethra can be obviously the most important determinant of the effi-
made as a catheter is withdrawn from the urethra dur- cacy of a particular drug for the animal.
ing voiding (micturitional urethral pressure profilom-
etry). The area of maximum pressure drop along the DECREASED URETHRAL PRESSURE
urethra indicates the site of obstruction.16 In dogs, sym- Acquired Incompetence of the Urethral
pathetic and somatic reflex dyssynergia can be differen- Sphincter Mechanism
tiated by localization of the spinal cord lesion,1 mea- Diagnosis
surement of urethral electromyographic activity during Incompetence of the urethral sphincter mechanism
detrusor contraction,1,7,16 or more commonly by re- can be congenital or acquired. Acquired incompetence
sponse to medical therapy.1,7 may be a complication of ovariohysterectomy and is a
common cause of urinary incontinence in spayed fe-
Treatment male dogs.25,26 The electromyograms of the external
The objective of medical treatment for patients with urethral sphincter of these dogs are normal,27 and in-
functional urethral obstruction is to decrease urethral continence occurs mainly during periods of recumben-
resistance by decreasing the activity of smooth or skele- cy. These findings imply that the external urethral
tal muscle. Urethral pressure profilometry has been used sphincter is functional. The incontinence is frequently
to evaluate whether a decrease in urethral pressure results reversed by estrogen or α-adrenergic agonists.2,3,25,27–29
from administration of drugs prescribed to relax the urethra. Because α-adrenergic receptors are located predomi-
In experiments with normal cats, acepromazine,17 nantly on smooth muscle, the urethral incompetence
dantrolene,18 nifedipine,19 phenoxybenzamine,17,19 pra- most likely arises from insufficient smooth muscle
zosin, 20 succinylcholine, 18 and xylazine 19 have been function. However, the causes of acquired insufficiency
shown to decrease urethral pressure. Diazepam de- of the urethral sphincter mechanism are poorly under-
creased urethral pressure in cats in one study19 but did stood. This condition has been attributed to estrogen
not alter pressure in another.18 In cats, the site of pres- deficiency, adhesions between the vaginal stump and
sure decline on the profile did not always correspond to bladder neck that interfere with sphincteric activity,30 or
the exact anatomic location of smooth or skeletal mus- damage to structures supporting the bladder during
cle, as would be predicted by each drug’s mechanism of ovariohysterectomy.31 Thus far, none of these causes has
action.19 been substantiated. Other factors may include breed,32
In dogs with functional urethral obstruction, di- obesity,33 tail docking,32 age-related changes in urethral
azepam and dantrolene are used most often to decrease musculature,3 and intrapelvic position of the neck of
urethral skeletal muscle tone.2,5,7 Urethral pressure pro- the bladder (“pelvic bladder”).31,34,35
filometry has not been used to evaluate the effect of di- The diagnosis is usually made by excluding other
azepam in dogs. Dantrolene and baclofen have each causes of urinary incontinence on the basis of history,
been shown to decrease urethral pressure in an experi- physical examination, contrast radiography of the uri-
mental canine model of somatic reflex dyssynergia.21 nary tract and vagina, and response to therapy. Urethral
Baclofen inhibits the spinal reflex activity of the puden- pressure profilometry can document incompetence of
dal nerve21–23; its clinical use in dogs has not been re- the urethral sphincter mechanism, but few specific cri-
ported. teria are available for interpreting profiles of inconti-
Phenoxybenzamine is used most often to decrease nent dogs that are suspected to have the condition.
urethral smooth muscle tone in dogs with functional One study using the perfusion method compared
urethral obstruction.2,5,7 Urethral pressure profilometry values from dogs with presumed incompetence of the
has shown that phenoxybenzamine decreases urethral urethral sphincter mechanism to continent dogs27,36
pressure.24 Prazosin and doxazosin have been used in (Table I). The dogs with presumed incompetence had
humans for relaxation of urethral smooth muscle, but significant reductions in maximum urethral pressure
their use in dogs has not been reported.16 and maximum urethral closure pressure. There were no
Because sympathetic and somatic reflex dyssynergia significant differences in functional profile length.27
are seldom differentiated in animals, combination drug Two studies using the more sensitive microtransducer

DIAZEPAM ■ PHENOXYBENZAMINE ■ ESTROGEN


Small Animal The Compendium May 1996

TABLE I
Urodynamic Measurements Taken by the Perfusion Methoda
Maximum Urethral Maximum Urethral Functional Profile
Pressure Closure Pressure Length
Sex (cm H2O) (cm H2O) (cm)

Females (n = 11) 46.45 ± 8.23 36.91 ± 8.20 6.20 ± 0.38


(Reference range) (90.18 ± 4.48) (79.72 ± 4.61) (8.68 ± 0.57)

Males (n = 8) 58.38 ± 8.81 48.63 ± 8.68 25.94 ± 1.67


(Reference range) (109.77 ± 11.52) (99.77 ± 11.71) (24.00 ± 0.92)
aMeasurements taken from unsedated, surgically sterilized incontinent dogs with presumed incompetence of the urethral sphincter
mechanism.

method demonstrated significant differences between ing intermittent pressure to the abdomen. With in-
continent female dogs and incontinent female dogs creased abdominal pressure (as in coughing or barking),
with presumed incompetence of the urethral sphincter the increase in proximal urethral pressure should be
mechanism.37,38 The first study compared 50 continent equal to or greater than the increase in intravesical pres-
female dogs (some spayed, some intact) to 50 inconti- sure.16 The stressed simultaneous urethral pressure pro-
nent female dogs (some spayed, some intact).37 The sec- file will show positive pressure spikes on the intravesical
ond study compared 44 continent intact female dogs and intraurethral traces at the times that pressure is
with 46 incontinent spayed female dogs.38 From these stud- being applied to the abdomen. When the intravesical
ies, the investigators reached the following conclusions: tracing is subtracted from the intraurethral tracing, pos-
itive and negative spikes result. Negative spikes indicate
■ In 86% of incontinent dogs with presumed incom- moments when intravesical pressure exceeded intra-
petence of the urethral sphincter mechanism, ure- urethral pressure.
thral pressure was equal to or less than intravesical A recent study evaluating the use of stressed simul-
pressure in at least part of the profile. This finding taneous urethral pressure profilometry found signifi-
was also observed in 26% of continent dogs. Ure- cant differences between 25 continent (some spayed,
thral pressure was equal to or less than intravesical some intact) and 25 incontinent spayed female dogs
pressure throughout the entire profile in 34% of in- with presumed incompetence of the urethral sphincter
continent dogs. This finding was not observed in mechanism39 (Table III). The investigators determined
continent dogs.37 that the percentage of negative spikes extending below
■ The maximum urethral closure pressure was signifi- resting intravesical pressure was significantly greater in
cantly lower in incontinent dogs37,38 (Table II) and incontinent than in continent female dogs.39
tended to occur in the caudal third of the profile Various methods of urethral pressure profilometry
rather than the middle third, as is observed in conti- can be used to demonstrate significant differences be-
nent dogs.37 tween groups of continent and incontinent dogs. How-
■ A maximum urethral closure pressure less than 7.4 ever, the measurements from these two groups overlap
cm H2O had a sensitivity of 94% and specificity of considerably, thus limiting the usefulness of urethral
89% for diagnosing this condition.38 The maximum pressure profilometry as a definitive diagnostic test for
urethral closure pressure was never less than 4.8 cm incompetence of the urethral sphincter mechanism.
H2O in continent dogs and never greater than 9.4 Elimination of other causes of urinary incontinence
cm H2O in incontinent dogs.38 and demonstration of a pelvic position of the neck of
■ The functional profile length was significantly short- the urinary bladder may be more useful than urethral
er in incontinent females.37 pressure profilometry for diagnosis of incompetence of
the urethral sphincter mechanism in canine patients.40
A new technique to evaluate the competence of the
urethral sphincter mechanism is called stressed simulta- Medical Therapy
neous urethral pressure profilometry. 33,39 With this Medical therapy can increase the tone of the smooth
technique, intravesical pressure and urethral pressure muscle of the proximal urethra. Either reproductive
are measured as abdominal pressure is varied by apply- hormones (estrogen or testosterone) or an α-adrenergic

STRESSED SIMULTANEOUS URETHRAL PRESSURE PROFILOMETRY ■ ABDOMINAL PRESSURE


Small Animal The Compendium May 1996

agonist is administered. Im- propanolamine significantly


TABLE II
proved continence in spayed increased the maximum ure-
Urodynamic Measurements Taken
female dogs after estrogen by the Microtransducer Method a thral pressure and the maxi-
therapy suggests that the in- mum urethral closure pres-
competence of the urethral Maximum Urethral sure to within the normal
sphincter mechanism is a Closure Pressure range. 27 Side effects of
consequence of ovariohys- Number of Dogs (cm H 2 O) Reference phenylpropanolamine thera-
terectomy. Estrogen im- py include restlessness, irri-
50 0–10.4 37
proves urethral competence, (2.6–27.0) b tability, hypertension, and
most likely by increasing the anorexia.42
sensitivity of adrenergic re- 46 4.6 ± 2.3 38 The tricyclic antidepres-
ceptors of urethral smooth (18.6 ± 10.5)b sant imipramine has also
muscle to sympathetic in- aMeasurements obtained from anesthetized incontinent been used successfully in
nervation.28 female dogs with presumed incompetence of the urethral some dogs with incompe-
In some dogs, however, sphincter mechanism. tence of the urethral sphinc-
the improvement in con- bNumbers in parentheses represent reference ranges. ter mechanism, presumably
tinence is not maintained by inhibiting presynaptic
with estrogen therapy. Seri- norepinephrine reuptake.28
ous complications of estro- TABLE III Imipramine has been associ-
gen therapy include bone Percentage of Negative Spikes Below Resting ated with a wide variety of
marrow suppression, skin Intravesical Pressure on the Subtracted, Stressed complications in humans.43
39
disease, and attraction of Simultaneous Urethral Pressure Profile Description of its clinical
males.28 use in dogs is lacking.
Percentage of
Estrogen deficiency is We prefer to use phenyl-
Patients Negative Spikes
probably not the sole cause propanolamine for control
of acquired incompetence of Continent female dogs (n = 25) 30.61± 17.12 of incompetence of the ure-
the urethral sphincter mech- thral sphincter mechanism
anism because estrogen con- Incontinent female dogs (n = 25) 67.4 ± 17.12 because of its lower risk of
centrations are similar be- toxicity. No studies have
tween continent anestrous dogs and incontinent spayed evaluated the long-term risks associated with these
dogs. 27 Nor does continence improve in all of the medications.
spayed female dogs treated with estrogen. Also, most
spayed female dogs remain continent, and the interval Surgical Therapy
between ovariohysterectomy and the onset of inconti- Several surgical treatments for acquired incompe-
nence can be prolonged.29 tence of the urethral sphincter mechanism have been
In an experiment, ovarian tissue was implanted be- described in the veterinary literature44–54 (Table IV). In
neath the serosa of the stomach and intestine after ovar- humans, surgical procedures have been designed to
iohysterectomy to maintain estrogen levels in 66 dogs. provide mechanical compression of the urethra and/or
The procedure did not prevent 13 of these dogs from move the neck of the bladder into the abdomen.16,44
33
developing incontinence later. We have not seen any Sling Urethroplasty. An early attempt at surgical
studies that show whether urethral pressure measure- correction of acquired incompetence of the urethral
ments are different in continent spayed female dogs sphincter mechanism in a dog was reported in 1980.
than in continent intact female dogs. No differences in Sling urethroplasty combined with estrogen therapy re-
urethral pressure were detected between intact and stored continence in a spayed female dog with a pelvic
spayed female cats.41 urinary bladder.45 Seromuscular flaps were created from
Alpha-adrenergic stimulation serves to maintain tone the ventral46 or dorsal45 midline of the urinary bladder
in the smooth muscle of the proximal urethra. There- neck and sutured like a sling around the proximal ure-
fore, direct-acting α-adrenergic agonists may effectively thra. The seromuscular defect was then closed. The use
treat incompetence of the urethral sphincter mecha- of this single procedure in other dogs has not been re-
nism without the serious side effects of estrogen thera- ported.
py. Phenylpropanolamine or ephedrine is commonly Colposuspension. Colposuspension is the most fre-
used.2,3,25,27–29,38 In male and female dogs with incompe- quently performed technique.47 The procedure is used
tence of the urethral sphincter mechanism, phenyl- in incontinent female dogs in which the neck of the

ESTROGEN ■ PHENYLPROPANOLAMINE ■ IMIPRAMINE


Small Animal The Compendium May 1996

TABLE IV
Surgical Techniques Used to Correct Incompetence of the Urethral Sphincter Closure Mechanism
Number of Dogs Number of Dogs
That Had That Had
Preoperative Postoperative
Procedure Number of Dogs Profilometry Profilometry Clinical Outcome

Colposuspension 26 26 26 Not reported50


150 104 Not reported 53% resolved, 37% improved,
9% no improvement44,49
33 Not reported Not reported 54% resolved, 36% improved,
9% no improvement48

Polytef injection 22 Not reported Not reported 77% resolved after 1 or 2


injections, 23% no or
transient improvement53

Cystourethropexy 10 6 1 60% resolveda, 30%


improveda, 10% no
improvement51

Urethral banding 3 1 1 2 resolved, 1 surgical failure


(implant had to be removed)52
3 2 1 1 no improvement, 2 surgical
failures (implant had to be
removed)

Sling urethroplasty and 5 Not reported Not reported 2 resolved, 2 resolved with
colposuspension estrogen, 1 no improvement47

Sling urethroplasty 1 Not reported Not reported Resolved with estrogen45


a With or without phenylpropanolamine.

bladder is abnormally located within the pelvic canal the prepubic tendon. These findings suggest that col-
rather than in the abdomen.48 When the neck of the ca- posuspension not only restores continence by bringing
nine bladder is in its normal position in the abdomen, the urinary bladder neck to an intraabdominal posi-
elevations in abdominal pressure increase pressure in tion; it also may mechanically compress the proximal
the bladder neck and proximal urethra at the same time urethra. Both factors increase transmission of pressure
as bladder pressure increases. In contrast, when the to the proximal urethra and thus improve continence.50
bladder neck is in the pelvic canal in a dog with an in- Urethral Compression. Additional surgical methods
competent urethral sphincter mechanism, elevations in for the treatment of acquired incompetence of the ure-
abdominal pressure increase pressure in the bladder but thral sphincter mechanism have been described but
cause no concomitant increase in pressure in the blad- have shown variable results and are performed infre-
der neck and proximal urethra. Consequently, urine quently (Table IV). With cystourethropexy, the sero-
flows into the urethra. muscular layer of the proximal urethra is sutured to the
Colposuspension anchors the vagina to the prepubic ventral abdominal wall, thus decreasing the size of the
tendon on either side of the proximal urethra, thus urethral lumen when the linea alba is apposed.51 Encir-
repositioning the bladder neck and proximal urethra in cling the proximal urethra with a synthetic band (ure-
the abdomen.44,47,49,50 In a study of 20 dogs, urethral thral banding)52 or injecting polytef into the urethral
pressure profilometry was performed before and after submucosa under cystoscopic guidance can provide
colposuspension. After surgery, a urethral pressure peak mechanical compression of the urethra.53 Experimental
was observed at the level of the vaginal attachment to creation of a urethral intussusception in clinically nor-

PELVIC BLADDER ■ PREPUBIC TENDON ■ POLYTEF INJECTION


Small Animal The Compendium May 1996

mal dogs but not in dogs with urinary incontinence ital incompetence of the urethral sphincter
was recently described.54 mechanism.4,57,58
During surgery, the surgeon assesses the compression One explanation for the incompetence of the ure-
of the urethra by squeezing the bladder to estimate re- thral sphincter mechanism in dogs with ureteral ectopia
sistance to urine outflow. Consequently, dysuria has is mechanical disruption of the sphincter mechanism
been a frequently described postoperative complica- by remnants of ectopic ureter coursing through the
tion.45,47,51–53 Intraoperative urethral pressure profilom- proximal urethra.57 Dogs with ureteral troughs do have
etry has not been described but could theoretically be a higher incidence of postoperative incontinence than
used to measure the amount of urethral pressure result- do dogs with simple intramural ectopic ureters.56 Once
ing from surgical compression of the urethra. other diagnostic differentials for persistent incontinence
We use a water manometer attached to a cystostomy are eliminated by contrast radiography (excretory uro-
catheter to measure intravesical pressure during the ure- gram, retrograde vaginourethrogram, and cystogram)
thral banding procedure. The bladder is compressed and urine culture, urethral pressure profilometry can be
until urine appears at the vulva, and the intravesical used to evaluate the function of the urethral sphincter
pressure is recorded. The band is tightened until intra- mechanism.55
vesical pressure is increased by 10 to 15 cm H2O dur- One study has evaluated whether presurgical urethral
ing bladder compression. Too few dogs have undergone pressure profiles could be used to predict whether the
this procedure for any conclusions on efficacy to be dog would be continent after correction of ureteral ec-
drawn. topia. Also addressed was whether increased urethral
Urethral pressure profilometry has been infrequently pressure after administration of phenylpropanolamine
used for the postoperative evaluation of urethral pres- before surgery could be used to predict the drug’s suc-
sure. After urethral banding in one dog, the postopera- cess in controlling any postoperative incontinence.59
tive maximum urethral pressure increased to 95 cm Nine dogs with confirmed ureteral ectopia were evalu-
H2O (twice the preoperative urethral pressure) near the ated. Three of the nine dogs had normal preoperative
implant. The dog was continent 1 year later.52 After maximum urethral closure pressure (>19 cm H2O) for
cystourethropexy in one dog, the postoperative maxi- the type of sedation used35 and were determined to
mum urethral pressure increased to 90 cm H2O, 30 cm have competent urethral sphincter mechanisms. Of
H2O greater than the preoperative urethral pressure. these three dogs, only one became permanently conti-
This reading was within the reference range established nent after correction of ectopic ureter. The other two
by the investigator; however, the dog remained inconti- remained incontinent. Both of these dogs had ureteral
nent.51 troughs.
These results demonstrate the potential difficulty of Six of the nine dogs had a decreased preoperative
using urethral pressure profilometry to determine the maximum urethral closure pressure (<19 cm H2O). All
degree of urethral pressure necessary to restore conti- six were treated before surgery with phenyl-
nence and reflect the variable nature of the technique. propanolamine, and the profilometry was repeated. In
More controlled studies will be necessary to determine two dogs, the maximum urethral closure pressure in-
whether urethral pressure profilometry can be used for creased to greater than 19 cm H2O. In both of these
this purpose. At present, preoperative urethral pressure cases, it was correctly predicted that the dogs would be
profilometry cannot predict whether surgery will be continent with medication after surgery. Of the four
successful in restoring continence.49 dogs that did not respond to phenylpropanolamine be-
fore surgery, two remained incontinent while treated
Ureteral Ectopia with phenylpropanolamine after surgery. The other two
Persistent incontinence after repair of ureteral ectopia became continent or had improved continence when
occurs in dogs.4,55–58 Reports on the incidence of post- treated with higher doses of phenylpropanolamine than
operative incontinence range from 29% to 67%.59 In- those used before surgery.59 This study, however, in-
continence can result from inadequate surgical treat- volved too few dogs for the results to be statistically sig-
ment (e.g., patent distal ureteral segments,55 missed nificant.
ureteral branches,57 undiagnosed bilateral ectopia55), For several reasons, we do not use urethral pressure
pelvic or hypoplastic urinary bladder, 57 persistent profilometry for dogs with ectopic ureters. The ectopic
urinary tract infection, 56 or vestibulovaginal mal- ureter might accidentally be catheterized during the
formation. 55 Other explanations include hormonal procedure. Also, the resting urethral pressure could be
imbalances and neurogenic abnormalities.56 The incon- altered when large urethroscopy instruments are used
tinence is frequently attributed to coexisting congen- to guide urethral catheterization for the profilometry.

WATER MANOMETER ■ CONTRAST RADIOGRAPHY


The Compendium May 1996 Small Animal

Finally, it is difficult to interpret ■ If innervation of the external


the profile because of the in- Criteria for Assessing urethral sphincter was dis-
fluence of the ectopic ureter rupted, electromyographic
coursing across the proximal ure- Pudendal Nerve Function activity was absent and post-
thra. prostatic urethral pressure
Ease of bladder expression decreased significantly. 68–70
Prostate Problems Presence of fecal incontinence These changes eventually re-
Urinary incontinence is a fre- Ability to interrupt urination versed in up to 61% of the
quent complication of prostatic Anal sphincter tone and sensation cats.68,69
disease and prostate surgery. 60–65 Perineal reflex ■ Urinary incontinence result-
Profilometry has documented Bulbocavernosus reflex ed from surgical injury only
decreased urethral pressure in Electromyography when urethral smooth mus-
dogs with clinical prostatic dis- External anal sphincter cle and the external urethral
ease.61 After total prostatectomy External urethral sphincter sphincter were both dam-
for prostatic disease, every one of Urethral pressure profilometry aged.70
six dogs had postoperative uri- Sacral somatosensory evoked potentials ■ Preservation of the dorsal at-
nary incontinence.63 In another tachment of the urethra
study, 13 of 14 dogs with pro- (where the main branch of
static disease were incontinent after total prostatecto- the pudendal nerve and pelvic plexus terminate)
my.61 Other types of prostatic surgery have a much maintained the preoperative electromyographic ac-
lower incidence of postoperative incontinence.61,63–65 tivity and urethral pressure profiles.67,68
Only 2 of 15 dogs undergoing surgical drainage or ■ Cats with abnormal urethral pressure profiles had
marsupialization of the prostate became inconti- the same incidence of urinary tract infection as cats
n e n t in one study 63 and three of nine dogs in with normal urethral pressure profiles.66
61
another.
When urethral pressure profilometry is performed for Loss of electromyographic activity of the external
incontinent dogs after prostate surgery, the high- urethral sphincter and decreased urethral pressure near
pressure zone (maximum urethral closure pressure) cre- the external sphincter suggest that urinary incontinence
ated by the external urethral sphincter is decreased or after perineal urethrostomy is caused by disruption of
absent and urethral electromyographic activity is de- the function of the external urethral sphincter. These
creased.61,64 Function of the urethral smooth muscle is findings demonstrate the need to preserve the dorsal at-
not significantly altered. These findings suggest that tachment of the urethra and thus avoid disruption of
urinary incontinence resulting from prostatic disease or the innervation of the external urethral sphincter dur-
prostate surgery is created by damage to the external ing perineal urethrostomy. Because postoperative pro-
urethral sphincter. files do not correlate with urinary tract infection, fac-
After prostatectomy, dogs that had had prostatic dis- tors other than decreased urethral pressure must
ease behave differently than dogs that had not had predispose cats to bacterial infection of the urinary tract
prostatic disease. When total prostatectomy was per- after perineal urethrostomy. Cats should be monitored
formed in 10 dogs without clinical prostatic disease, carefully for recurrent urinary tract infection after any
none developed incontinence and urodynamic alter- perineal urethrostomy procedure.
ations were minimal.62
Lower Motoneuron Disease
Perineal Urethrostomy Lesions of the sacral spinal cord, sacral roots, or
In cats, urinary incontinence and lower urinary tract pudendal nerve decrease urethral pressure. The sacral
infection may occur after perineal urethrostomy. A de- spinal cord segments are contained within the fifth
crease in resting urethral pressure after perineal ure- lumbar vertebra (L-5). Any lesion from L-5 caudally
throstomy has been demonstrated using urethral pres- can affect pudendal and pelvic nerve function,71 thus
66
sure profilometry and is attributed to disruption of altering the function of the external urethral sphincter
the nerve fibers of the pudendal nerve and pelvic plexus and detrusor muscle, respectively. Because of the fre-
during intrapelvic dissection.66,67 Measuring urethral quency of detectable neurologic abnormalities, a com-
pressure in cats after perineal urethrostomy using vari- plete neurologic examination is usually sufficient to
ous urethral dissection techniques yielded the following evaluate the integrity of the pudendal nerve.
observations: Pudendal nerve damage that reduces the anal reflex

PROSTATECTOMY ■ URINARY TRACT INFECTION ■ PELVIC PLEXUS


Small Animal The Compendium May 1996

would induce spontaneous electromyographic activity North Am Small Anim Pract 18(3):529–554, 1988.
indicative of denervation. Therefore, urethral pressure 7. Oliver JE: Dysuria caused by reflex dyssynergia, in Kirk RW
(ed): Current Veterinary Therapy. VIII. Small Animal Prac-
profilometry is rarely used to diagnose loss of pudendal tice. Philadelphia, WB Saunders Co, 1983, pp 1088–1089.
innervation. The profile would demonstrate decreased 8. Awad SA, Downie JW: Sympathetic dyssynergia in the re-
urethral pressure in the area of the external urethral gion of the external sphincter: A possible source of lower uri-
sphincter. Criteria for assessing external urethral nary tract obstruction. J Urol 118:636–640, 1977.
sphincter and pudendal nerve function have been pro- 9. Downie JW, Awad SA, Smith DA: A sympathetic compo-
nent in the external urinary sphincter: A source of obstruc-
posed (see the box). Pelvic nerve function can be evalu- tion in neurogenic disorders. Can Fed Biol Soc 19:439, 1976.
ated by a cystometrogram. 10. Awad SA, Downie JW, Lywood DW, et al: Sympathetic ac-
Urethral pressure profilometry in cats with dys- tivity in the proximal urethra patients with urinary obstruc-
autonomia has not been described. The urethral pres- tion. J Urol 115:545–547, 1976.
sure profile would be expected to demonstrate loss of 11. Awad SA, Downie JW, Kiruluta HG: Alpha-adrenergic
agents in urinary disorders of the proximal urethra. Part II.
smooth muscle tone to the proximal urethra because of Urethral obstruction due to “sympathetic dyssynergia.” Br J
sympathetic dysfunction and possibly evidence of de- Urol 50:336–339, 1978.
creased pudendal function. 12. Rudy DC, Awad SA, Downie JW: External sphincteric
dyssynergia: An abnormal continence reflex. J Urol 140:
105–110, 1988.
SUMMARY 13. Filippich LJ, Read RA, Riesz G: Functional urethral obstruc-
Urethral pressure profilometry can be useful for in- tion in a cat. Aust Vet Pract 19:202–206, 1989.
vestigating urinary incontinence in selected patients. Its 14. Abel BJ, Jameson RM, Gibbon NOK, et al: The neuropath-
utility for diagnosis of incompetence of the urethral ic urethra. Lancet 2:1229–1230, 1974.
sphincter mechanism in individual dogs is limited by 15. Moreau PM, Lees GE, Hobson HP: Simultaneous cystom-
etry and uroflowmetry for evaluation of micturition in two
an overlap in measurements between clinically normal dogs. JAVMA 183(10):1084–1088, 1983.
and incontinent dogs. The urethral pressure profile has 16. Wein AJ: Neuromuscular dysfunction of the lower urinary
been useful for documenting the effect of various drugs tract, in Walsh PC (ed): Campbell’s Urology. Philadelphia,
on urethral pressure and for elucidating the mecha- WB Saunders Co, 1992, pp 571–613.
nisms by which urethral surgery can either result in uri- 17. Marks SL, Straeter-Knowlen IM, Knowlen GG, et al: The
effects of phenoxybenzamine maleate on urethral pressure
nary incontinence or be used to restore continence. profiles of anesthetized healthy male cats. J Vet Intern Med
7(2):122, 1993.
18. Straeter-Knowlen IM, Marks SL, Speth RC, et al: Effect of
succinylcholine, diazepam, and dantrolene on the urethral
About the Authors pressure profile of anesthetized, healthy, sexually intact male
Drs. Gookin, Stone, and Sharp are affiliated with the De- cats. Am J Vet Res 55(12):1739–1744, 1994.
partment of Companion Animal and Special Species 19. Mawby DI, Meric SM, Crichlow EC, et al: Pharmacological
Medicine, College of Veterinary Medicine, North Carolina relaxation of the urethra in male cats: A study of the effects
State University, Raleigh, North Carolina. Dr. Stone is a of phenoxybenzamine, diazepam, nifedipine and xylazine.
Can J Vet Res 55:28–32, 1990.
Diplomate of the American College of Veterinary Sur-
20. Frenier SL, Knowlen GG, Speth RC, et al: Urethral pressure
geons, and Dr. Sharp is a Diplomate of the American Col- response to α-adrenergic agonist and antagonist drugs in
lege of Veterinary Internal Medicine (Neurology). anesthetized healthy male cats. Am J Vet Res 53(7):1161-
1165, 1992.
21. Teague CT, Merrill DC: Effect of baclofen and dantrolene
on bladder stimulator-induced detrusor-sphincter dyssyner-
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